The Oct. 18 issue of Annals of Internal Medicine describes two new diabetes treatments: exenatide, an injected drug; and inhaled insulin. Both treatments have pluses and minuses and were tested on people with type 2 diabetes who were already taking two oral blood-sugar-lowering drugs but whose levels were not under control.

A 26-week trial comparing benefits and harms of exenatide and insulin glargine injections in 551 patients with type 2 diabetes found that both drugs improved overall sugar control, but patients in the exenatide group lost about five pounds, whereas patients in the insulin glargine group gained about four pounds (Article, p. 559).

Patients in the exenatide group had more bad side effects, such as nausea, vomiting and diarrhea, and more patients in this group dropped out of the study than in the insulin glargine group.

Neither drug helped patients achieve recommend fasting sugar levels; only 21.6 percent of the exenatide group and 8.6 percent of the insulin group achieved target blood sugar levels. Also the study participants included only a few African-Americans, a group with a high rate of type 2 diabetes.

A 12-week trial comparing effects of inhaled insulin (a fast-acting insulin) with oral drug therapy in 309 patients, assigned patients to one of three treatments: inhaled insulin alone, inhaled insulin added to two blood-sugar-lowing oral drugs, or oral drug therapy alone (Article, p. 549).

Researchers found that both groups receiving insulin therapy improved blood sugar levels. Patients receiving inhaled insulin gained more weight and had more episodes of hypoglycemia (abnormally low level of blood sugar or glucose) and cough than the oral therapy alone group.

The study didn't compare inhaled insulin with injected insulin and only lasted 12 weeks, so the drug's long-term effects on the lungs or on diabetes control are not clear. The current inhaler device, used before each meal, is large and only allows dosing of 2.5 to 3.0 units of insulin, while injected insulin currently allows for finer adjustments in dose.

An editorial writer says that the two new treatments provide much-needed options for treating the later stages of diabetes (Editorial, p. 609). However, until development of "precise molecular targets" for type 2 diabetes, lifestyle choices (increasing exercise and reducing weight) will be the cornerstone of managing this debilitating and increasingly common disease.

Susan Anderson
sandersonacponline
215-351-2656
American College of Physicians
Annals of Internal Medicine tip sheet for Oct. 18, 2005
acponline